<form id="edit-form" class="form-horizontal" role="form" data-toggle="validator" method="POST" action="">

    <div class="form-group">
        <label class="control-label col-xs-12 col-sm-2">{:__('Agency_name')}:</label>
        <div class="col-xs-12 col-sm-8">
            <input id="c-agency_name" data-rule="required" class="form-control" name="row[agency_name]" type="text" value="{$row.agency_name|htmlentities}">
        </div>
    </div>
    <div class="form-group">
        <label class="control-label col-xs-12 col-sm-2">{:__('Amount')}:</label>
        <div class="col-xs-12 col-sm-8">
            <input id="c-amount" data-rule="required" class="form-control" step="0.01" name="row[amount]" type="number" value="{$row.amount|htmlentities}">
        </div>
    </div>
    <div class="form-group">
        <label class="control-label col-xs-12 col-sm-2">{:__('Remit_type')}:</label>
        <div class="col-xs-12 col-sm-8">
            {:build_select('row[remit_type]', $remitTypeList, $row.remit_type, ['class'=>'form-control selectpicker', 'data-rule'=>'required'])}
        </div>
    </div>
    <div class="form-group">
        <label class="control-label col-xs-12 col-sm-2">{:__('Remit_time')}:</label>
        <div class="col-xs-12 col-sm-8">
            <input id="c-remit_time" class="form-control datetimepicker" data-date-format="YYYY-MM-DD HH:mm:ss" data-use-current="true" name="row[remit_time]" type="text" value="{$row.remit_time}">
        </div>
    </div>
    <div class="form-group">
        <label class="control-label col-xs-12 col-sm-2">{:__('Remit_no')}:</label>
        <div class="col-xs-12 col-sm-8">
            <input id="c-remit_no" class="form-control" name="row[remit_no]" type="text" value="{$row.remit_no|htmlentities}">
        </div>
    </div>
    <div class="form-group">
        <label class="control-label col-xs-12 col-sm-2">{:__('Remarks')}:</label>
        <div class="col-xs-12 col-sm-8">
            <input id="c-remarks" class="form-control" name="row[remarks]" type="text" value="{$row.remarks|htmlentities}">
        </div>
    </div>
 
    
    {include file="pt/agency_remit/_remit_orders_table" /}
    
    <div class="form-group layer-footer">
        <label class="control-label col-xs-12 col-sm-2"></label>
        <div class="col-xs-12 col-sm-8">
            <button type="submit" class="btn btn-primary btn-embossed disabled">{:__('OK')}</button>
        </div>
    </div>
</form>
